Put mental health care within reach of everyone

An Ontario government agency has floated a gamechanging idea that could put life-saving mental health treatment within reach for many who desperately need it.

Health Quality Ontario says proven treatments provided by psychologists, nurses, youth counsellors and social workers — such as cognitive behavioural therapy — should be covered by public health insurance.

The evidence is clear for these specific psychotherapies, which are the first line of treatment for nearly every type of child or youth mental illness. For example, randomized controlled trials show that cognitive behavioural therapy (CBT) for anxiety noticeably reduces symptoms and improves function in 60 per cent of kids — a better result than medication. For severe anxiety, a combination of CBT and medication is successful with 80 per cent of patients.

Providers of such therapies exist, but many can’t afford their services. This is a problem of access, not availability. With any physical ailment, public health insurance entitles you to care. A fracture will be seen after a heart attack, but it will be tended to. Not so for mental health and addictions. You are only guaranteed care for the mental health equivalent of barely breathing — if your condition is so severe that you are a threat to yourself or others.

Parents will do anything they can afford — and often things they can’t — for their children. And so a robust, privately funded mental health sector exists. For psychology alone, it’s estimated Canadians spend nearly $1 billion annually, out-of-pocket and through private insurance.

In the U.S., multiple health-care payers drive up cost and leave many without coverage. Europe’s parallel private and public systems lead to fewer universal services and more inequitable access. Sadly, these are defining features of mental health services here: multiple payers and a parallel private system. We should learn from others to avoid their mistakes, not replicate them.

People who have the means can buy counselling or residential treatment for addiction, if it exists. Those without the ability to pay line up for publicly funded services. Everyone scrambles, trying to cover or avoid the gaps between public and private services, trying to provide or get needed care — too often without success. But untreated chronic conditions get worse. And so the publicly funded mental health system is now a crisis response safety net.

At the Children’s Hospital of Eastern Ontario in Ottawa, our entire 19-bed psychiatric unit has gradually become dedicated to crisis stabilization. Nearly all admissions come through Emergency and 41per cent of kids are admitted involuntarily. They stay an average of six days, long enough to develop a safety plan and line up community services (including private services, if possible). We have dramatically reduced outpatient wait times by reorganizing our model of care. However, capacity is steadily eroding as demand for service and patient acuity both rise, while public funding does not.

Ottawa’s Youth Services Bureau runs a 24-hour crisis line, mobile crisis response team, short-term crisis residence and walk-in clinic staffed by youth counsellors. It’s all free of charge, though not funded by the Ministry of Health.

GPs and pediatricians often feel ill-equipped to deliver acute mental health care, yet know a referral within the public system means a long wait at a critical time.

Great initiatives are popping up all over: programs for at-risk youth, one-number-to-call projects, funding for universities to help students. These are important services. CHEO has helped launch many.

But they are workarounds. They don’t create a universal, public system.

Add up the cost of all these various programs with private spending on mental health and addictions — and knowing Canada’s annual figure for private spending on health is approaching $60 billion — it’s clear that our country has the means to ensure early, appropriate and ongoing mental health care for all who need it. I’ve marvelled at youth whose resilience got them through all these barriers to accessing care. I’ve sat with anguished and angry parents, sometimes in funeral homes. We can and must do better.

The genius of federalism is that when something works in one province, others follow. Saskatchewan’s leadership gave us medicare, after all. Ontario wants to do the same with pharmacare for children and young adults.

Prime Minister Justin Trudeau decided to make federal health transfers conditional on improving access to mental health care — particularly for kids. There’s an opportunity and an imperative to lead.

“There is no health without mental health” is a catchy slogan. Health Quality Ontario is suggesting a way to also make it a central organizing principle of our health care system

Alex Munter is president and CEO of the Children’s Hospital of Eastern Ontario.